In Baltimore, Mapping The World Of Addiction

Addicts' movements around Baltimore are mapped onto images like this, showing levels of violence in each neighborhood. Other maps track things like visible drug use and vacant housing — all factors that may contribute to an addict's decision to use drugs.

Dr. Debra Furr-Holden
/ Johns Hopkins School of Public Health

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Originally published on November 20, 2011 5:32 pm

In East Baltimore, not far from rows of abandoned homes and empty warehouses, there's a space-age high rise housing an unusual methadone clinic.

"People come here and participate in studies, and in return they get treatment," Dr. Kenzie Preston tells Laura Sullivan, host of weekends on All Things Considered.

The lab is part of the National Institutes of Health. Preston, who heads research at the lab, and her colleagues provide methadone and drug testing to addicts who come here. Unlike other rehab programs, addicts don't get thrown out if they relapse. That's because researchers want to study those relapses and what makes them happen.

Preston says the 80 participants in her current study carry something very important: a smartphone that's programmed to let them track when they crave drugs, and when they use.

The phones are also set to beep randomly three times a day, and ask a series of questions: Where are you? What are you doing? How are you feeling?

The phones are partially disabled to reduce their street value, but associate scientist David Epstein says they don't have a problem with phones being lost or stolen.

"We tell them, if you lose or break one of these, we'll replace it and that's fine," he says. "But if you lose or break a second one, we're going to detox you from the methadone and you can't be in the study anymore. And we hardly ever have to do that. People know that they'd rather stay with us."

The point of the study is to understand why, at the precise moment, an addict decides to use. Epstein says if you ask someone about a relapse after the fact, he or she is going to have trouble recalling it accurately.

"People, whether it's someone who's addicted to drugs or anyone else in the world, make up stories that sort of explain their behavior," he says. "But if you could've been monitoring them in real time, you would see that things didn't happen quite the way they remembered."

Epstein says it's not lying, it's just the way the brain works. The smartphones enable researchers to capture that data in real time.

There's another component to the study: Along with the smartphones, addicts carry GPS loggers, about the size of a pager, that track their movements.

That means Epstein and his colleagues can follow on a map as an addict is sober for weeks, but one day after visiting a particular house or block, that person breaks down and relapses.

Knowing where addicts are when they use — or even when they're just thinking about using — gives researchers information about the kinds of places that make addicts want to use drugs. That's where Dr. Debra Furr-Holden comes in.

She's the head of the Drug Investigations, Violence and Environmental Studies lab at Johns Hopkins University. She and her team canvass Baltimore, block by block, looking for clues — such as discarded vial caps — about the character of each neighborhood.

"Oftentimes when people purchase heroin, they will flip the cap off the top between where they purchase and where they're using," she says. "And then we consider those to be the bread crumbs."

Abandoned houses, makeshift memorials to murder victims, visible evidence of drug use — these are all things Furr-Holden catalogues. Then, she turns that data into maps of Baltimore's neighborhoods.

Combining Furr-Holden's maps with the GPS data about addicts' movements could produce unique insights into how those neighborhoods affect people moving through them.

And, says Epstein, it could lead to new treatments, possibly using the smartphones.

"A sort of clinician in your pocket," he says. "You can give them on the spot feedback... and that does seem helpful."

For example, if an addict reports that he's in a high drug-use neighborhood and feeling stressed, the smart phone can flash a reassuring message: Most cravings only last 20 minutes. Hang in there.

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LAURA SULLIVAN, HOST:

In East Baltimore, not far from rows of abandoned homes and empty warehouses, there's a space-age high rise with an unusual methadone clinic.

DR. KENZIE PRESTON: So this is a research lab where people come here and participate in studies, and as part of those studies, they get treatment.

SULLIVAN: Dr. Kenzie Preston runs the program. It's part of the National Institutes of Health. And unlike other clinics, addicts who come here don't get thrown out if they keep using. That's because what researchers here really want to do is study them.

Every week, 80 people sit by rows of magazines and wait for methadone and a drug test. But when they walk out the door, Preston says they take something very important with them: a smartphone that they can use to track when they crave drugs and when they actually use.

Research associate Dave Reamer programs the phones. So what does this say?

DAVE REAMER: So it's saying what happened? And they have two answer choices right now: I craved without using or I used. So we'll just pick I craved without using and we tap next and it goes to the next question and says, which drugs were involved? And...

SULLIVAN: The phones are also programmed to beep randomly three times a day and ask a series of questions: Where are you? How are you feeling? What are you doing? Almost all the addicts in this program answer the questions regularly and very few lose or sell their smartphones.

DAVID EPSTEIN: We tell them, you know, if you lose or break one of these, we'll replace it and that's fine.

SULLIVAN: That's David Epstein, an associate scientist with the program.

EPSTEIN: But if you lose or break a second one, we're going to detox you from the methadone and you can't be in the study anymore. And we hardly ever have to do that. People know that, you know, they'd rather stay with us, and they do. They take care of them.

SULLIVAN: The point of it all is to understand why, at the precise moment an addict decides to use, when maybe they've been sober all morning, for several days, or a week. Epstein says most people are shockingly bad at answering a question like, why did you have that relapse last week?

EPSTEIN: And when people - when you ask a question like that, people - whether it's someone who's addicted to drugs or whether it's anybody else in the world, people sort of make up stories that makes sense to them, that explained their behavior. But if you could've been monitoring them in real-time, you would see that things didn't happen quite the way they remembered and they're making up relationships that weren't really there.

SULLIVAN: It's called recall bias. Epstein says people aren't trying to lie; it's just the way our brains work. But with the smartphones, researchers get information in real time. There's one other component to this study and this is something new: Researchers are also tracking where the addicts use, what street, what neighborhood. Addicts in the study carry little GPS loggers about the size of a pager.

That means David Epstein and his colleagues can follow on a map as an addict is sober for weeks. But one day, after being in a particular house or area, the addict breaks down and uses.

EPSTEIN: When we first got the idea to start using GPS loggers, it was - we were becoming acquainted with a whole field of psychology that we hadn't known about before called behavioral geography, which is pretty much what it sounds like. It's the study of relationships between where people are and how they behave.

SULLIVAN: Knowing where addicts are when they use or crave drugs is also giving researchers a lot of information about the kinds of places that may make them want to use.

EPSTEIN: It doesn't mean anything in particular if you say that someone was stressed or that someone used on a particular corner in Baltimore. Whereas if you have an objective, generalizable characterization of that or if you can say, this was a place with a physical disorder score of blah, blah, blah and a violent score of blah, blah, blah, suddenly it's not just about Baltimore anymore; it's about urban environments, and we can begin to say things about human behavior and human surroundings.

SULLIVAN: How do you go about scoring every neighborhood in Baltimore? That's where Dr. Debra Furr-Holden comes in. She heads the Drug Investigation Violence and Environmental Studies lab at Johns Hopkins. Furr-Holden and her team canvas Baltimore block by block looking for clues about the character of each neighborhood.

DR. DEBRA FURR-HOLDEN: Things like discarded vial caps. So oftentimes, when people purchase heroin, they will flip the cap off the top between where they purchase and where they're using, and then we consider those to be the breadcrumbs.

FURR-HOLDEN: So if you look around, many of these houses are inhabited. They've got positive signage in the windows. There's evidence of landscaping. It's sending a signal out to the world we care about our block. And we could go three blocks over or even one block down, and it will look very different.

SULLIVAN: All of this has given researchers an idea. Back at the lab, David Epstein says they want to turn the smartphones into on-the-spot treatment.

EPSTEIN: Sort of a clinician in your pocket. You can give them on-the-spot feedback that's sort of tailored to what they put in, and that does seem helpful.

SULLIVAN: One day, the researchers hope the smartphones can tell an addict, look, you've been sober for two weeks. It looks like you're headed to this address. You know every time you go there you use a few hours later. Or even, this craving you're having will pass in 20 minutes. Hang in there. Transcript provided by NPR, Copyright NPR.